The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Increase intake of proteins, take vitamin C and zinc

Use care when walking to avoid bumping your limb

Cleanse the ulcer with soap and water

Apply cortisone cream to decrease itching

Put on compression stockings before getting out of bed

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale

Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.

Choice B rationale

Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.

Choice C rationale

Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.

Choice D rationale

Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.

Choice E rationale

Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.

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Correct Answer is D

Explanation

Choice A rationale

While it’s important for clients to understand their medications, not having received proper education on this medication is not a reason to withhold cefazolin.

Choice B rationale

Completing a full course of an aminoglycoside antibiotic does not contraindicate the use of cefazolin.

Choice C rationale

Being afebrile does not contraindicate the use of cefazolin. Antibiotics are used to treat bacterial infections, not just to reduce fever.

Choice D rationale

A prior anaphylactic reaction to penicillin is a contraindication for administering cefazolin. Cefazolin is a cephalosporin, and there is a risk of cross-reactivity and potential allergic reaction in clients who have a history of severe penicillin allergy.

A. Administer the PRN antianxiety medication. B. Call the rapid response team. C. Increase the intravenous infusion rate. D. Prepare for mechanical ventilation.

Correct Answer is B

Explanation

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives an order to administer cefazolin to a client diagnosed with a urinary tract infection. The nurse withholds the medication and notifies the health care provider because the client:

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

A patient diagnosed with peripheral arterial disease is being educated about the benefits of walking for exercise. What information should the nurse emphasize?

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